Bad Diagnosis For New Psychiatry 'Bible'

There's ADHD, OCD, DMDD, PTSD, along with hoarding disorder, oppositional defiant disorder and dissociative identity disorder. You will find all of them in the DSM, that's the Diagnostic and Statistical Manual of Mental Disorders, the so-called Bible of psychiatry. The fifth edition of the manual just came out after 14 years in the making, but instead of a round of applause, psychiatrists, psychologists, ethicists, even columnist are panning the book, saying it has outlived its usefulness.

Even the head of the National Institute of Mental Health, here with us today, wrote that, quote: Patients with mental disorders deserve better. But what exactly is better? What alternative do we have to categorizing patients according to their symptoms? Where are the hard data, the blood test, the biopsy, the EKG for diagnosing troubles of the mind?

And what about all the drugs that psychiatrists serve up? Is psychiatry a storefront for the drug industry? That's what we're going to be talking about today, and our number is 1-800-989-8255. We'll be talking about the state of psychiatry and the DSM, the new version of DSM that just came out this week.

Here, let me introduce my guests. Gary Greenberg is a practicing psychotherapist, author of "The Book of Woe: The DSM and the Unmaking of Psychiatry." He joins us from WNPR in Connecticut. Welcome back to SCIENCE FRIDAY.

GARY GREENBERG: Yeah, it's good to be back, hi Ira.

FLATOW: You're welcome. Tom Insel is the director of the National Institute of Mental Health, part of the National Institutes of Health in Bethesda, Maryland. He joins us by phone. Welcome back to SCIENCE FRIDAY, Dr. Insel.

THOMAS INSEL: Thank you, Ira, good to be here.

FLATOW: Jeffrey Lieberman is president of the American Psychiatric Association and professor and chairman of psychiatry at Columbia University here in New York. He also joins us. Welcome to SCIENCE FRIDAY, Dr. Lieberman.

JEFFREY LIEBERMAN: Thank you.

FLATOW: Let's get right into some of these issues about this. Dr. Lieberman, let me start with you. Tell us first what the DSM is supposed to be used for.

LIEBERMAN: The DSM is a guide or a manual, which assists health care providers in recognizing symptoms that patients may be suffering from in determining what is the most accurate diagnosis that should be applied to them. It's used really as a companion or a complement to the International Classification of Disease system, which is the coda that all doctors in all countries across the world use for designating disorders or illnesses that people suffer from.

But the ICD provides simply a name and a code number. It doesn't provide a descriptive list of the symptoms and signs and historical course that the illness follows. So the DSM provides really an elaboration or a list of the different elements that define the diagnosis.

FLATOW: All right, we're going to take a short break. We have lots of phone calls, 1-800-989-8255. You can also tweet us @scifri or go to our website at sciencefriday.com. We'll be right back after this break. Stay with us. I'm Ira Flatow. This is SCIENCE FRIDAY from NPR.

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FLATOW: I'm Ira Flatow. We're talking this hour about the controversy over the DSM-V, the bible of diagnosis, with my guests Gary Greenberg, Thomas Insel and Jeffrey Lieberman. 1-800-989-8255 is our number.

Dr. Insel, you've been quoted, and Dr. Lieberman did describe the DSM as sort of a dictionary. And you said that patients with mental disorders deserve better. What did you mean by that?

INSEL: That's a way of saying that we now have a dictionary to describe the disorders, just as Jeff said, but what we're really lacking is a deeper understanding and a way to do for people with mental disorders what we do typically for people with other medical problems, that is to have biomarkers, have predictors of who will respond best to which treatment, and have guides based on the biology of the illness that helps to tell us where the best treatments might come from in the future.

We're missing all that. So when I say they deserve better, what I mean is we've got to do more than just produce a dictionary. We've got to actually produce an encyclopedia, something that has much deeper information so that we can provide much better interventions, and ultimately get much better outcomes.

FLATOW: Gary Greenberg, you're most critical. The subtitle of your new book is "The DSM and the Unmaking of Psychiatry." What is wrong with the DSM?

GREENBERG: Well, you know, the DSM is - reflects both the best and the worst about American psychiatry. It certainly represents a sincere effort to understand mental illness. And if all it were was an attempt to create good clinician communication, then we wouldn't be sitting here and talking about it.

The problem with the DSM is that while psychiatrists would be quick to say it's not really a bible in the sense that it shouldn't be taken literally, it is a bible in the sense that it underlies psychiatry's authority. And with the kind of problem that Dr. Insel just described, which is that it doesn't go to the question of what actually mental illness is, and, in fact, its descriptions may not correspond or line up with whatever biochemical or genetic findings we come up.

What has happened is that psychiatry's gone - been led down the path by the DSM into a situation in which its disorders are constructs. They aren't real in the way that we generally expect diseases to be real. And this has - this is not just a philosophical problem. This is a real problem, because what happens is that research follows the DSM. And so doctors end up researching and scientists end up researching disorders that are, in some way, mythical.

So whatever uses the DSM...

FLATOW: Well, when you say mythical, and let me get into a couple of those. So you have schizophrenia or bipolar, or - you're saying these are mythical?

GREENBERG: Well, in my book - I interviewed Dr. Insel for my book, and he's a very forthright man, and he said look, this is a problem. Psychiatrists come to think that schizophrenia is real. But schizophrenia is not real in the sense, again, that we normally expect diseases to be real, as he just said, with biomarkers and so on.

What schizophrenia is is a label applied to a group of symptoms. But there may be many ways to get to those symptoms. And, in fact, to some extent, what we see is that the genetics especially, and with family history, show that a common genetic underpinning may lie underneath both schizophrenia and bipolar disorder. The most venerable distinction in the DSM is between bipolar disorder and schizophrenia, and yet it may be that they have a common pathway.

So the - it's like, look, using the DSM to understand the terrain of mental illness is like using a map of the moon to get around Manhattan.

LIEBERMAN: Ira, can I jump in here?

FLATOW: Sure.

LIEBERMAN: This is Jeffrey Lieberman. First of all, I think when Tom, you know, says we have to better, what he's doing is he's exhorting the biomedical research community and the psychiatric research community to really try and redouble efforts and break new ground and out of the procrustean mold of historical methods of diagnosis.

The truth is is that the progress that we've seen in psychiatric diagnosis has been less than we would have hoped for, and it's in large part because the brain is a tough organ, and the behavioral and mental functions of the brain represent the most highly evolved aspects of the human organism and in all of the animal kingdom.

When Gary says - I mean, Gary's argument is so philosophical and abstruse and so really minimally relevant to clinical practice. The nature of the way science leads the evolution of medicine and the refinement of diagnosis is such that you begin with the syndromal description, and from there, you deconstruct it into more specific, biologically defined subtypes.

Historically, we knew there was dementia. It came from many different sources: vascular disease, Alzheimer's disease, Parkinson's disease. But it wasn't until we could look at the brain, until we could image the brains, until we could determine the genetics, that we could define it into these subtypes.

When HIV was first identified, it was AIDS. It was simply a syndrome. But then Gallo and Montagnier identified the HIV virus, and from that, it led to targets that led to protease inhibitors and antiretroviral drugs, and now it's something that's survivable.

FLATOW: But - so you - but you don't have a virus that causes mental illness that you're willing to put your finger on, do you?

LIEBERMAN: That's what we're looking for.

FLATOW: You think it's that simple?

LIEBERMAN: Well, we're not looking for a virus, per se, but we're looking for, you know, the genetic and the neurobiological bases for these disorders. When those are found, we may - it may lead to the deconstructing of psychotic disorders like schizophrenia into multiple subtypes, the same way that we see now with breast cancer being defined by its molecular signatures and its genetic profile.

FLATOW: Dr. Insel, what - your name's been bandied around here by two other people.

INSEL: I love listening to other people talk about what I've said. That's great.

(LAUGHTER)

FLATOW: Well, what is your problem? Tell us what your problem - why you've decided to not use that book so much.

INSEL: We're not saying that clinicians shouldn't use it. One way to think about this is DSM is really what we have, along with ICD, but those are really for the bedside. And I'm talking to an audience in the biomedical research community that's at the bench, not at the bedside, most of the time.

And so, for the bench, we're looking for some way to do just what Jeff Lieberman said a moment ago: finding a way to deconstruct these classifiers and to say hey, yes this is what we currently call schizophrenia. This is what we currently call autism spectrum disorder, but perhaps that's not one problem, but multiple, five, six, seven, eight different diseases that are contributing.

Let's do the science without the presumption that it's a single disease. Let's do the science with the assumption that we have to actually pull this apart and begin to understand the subtypes if we're going to get to more selective treatments.

FLATOW: But yet, psychiatrists are willing to prescribe drugs for these illnesses without, them knowing exactly what they are.

INSEL: Well, we do that across medicine. We don't know exactly in the case of migraine, we don't have a really good biomarker for migraine, but we still have medications that are pretty helpful. So we work with the science that we have. I think the frustration that all of us have and some of what you hear at the - as you mention at the entry point of the show, some of what you hear about the frustration of DSM is that people would like to see us further along here than we are.

I don't blame the DSM for that. I think the problem has been that we haven't often asked the right questions, and frankly, sometimes we've been constrained by the diagnostic criteria we have. Our message to the research community, when we say we want you to move beyond this, is to tell them: Don't think of this as a bible.

We don't even want you to think of this as the Old Testament. Let's just think about this, for now, as something that's clinically useful, but it needs to change. And the only way to change is through getting much better scientific information.

FLATOW: But don't in-practice doctors rely on it as a bible so that they can prescribe medications that will be accepted at your drugstore?

LIEBERMAN: I don't think they rely on it as a bible. As I said before, it is a guide. You know, medicine is an art, as well as a science, and the descriptions of disease, whether it involves diseases that are known, there's known ideologies for or for which there's laboratory tests or X-rays, or which there's just symptomatic descriptions, the doctor uses this information, provided either in a textbook or in something like the DSM, to inform their clinical judgment.

And based on all of that, they try and make a determination as to what's ailing a patient, and if it conforms to a diagnosis. And that diagnosis then leads to treatment. The DSM doesn't say anything about treatment. It doesn't tell you what medication or what psychotherapy or what intervention to utilize. It simply describes the descriptive characteristics of a presumed disorder.

FLATOW: And Gary Greenberg, what's wrong with that?

GREENBERG: Well, nothing's particularly wrong with that, and I have to agree. Psychiatrists, like many doctors, don't - psychiatrists don't treat psychiatric disorders with psychiatric drugs. They're treating symptoms, and there's nothing wrong with that. There is a difference between psychiatry and the rest of medicine, which is that while it's true that migraine or other conditions can't be specified in the way we might like, many medical disorders can. The DSM doesn't have any disorders that can be specified biologically, and that's why you have antidepressants prescribed to treat anxiety disorders and anti-anxiety drugs used for antipsychotic disorders and antipsychotic drugs used for mood disorders, because there are no drug treatments targeted to these disorders.

LIEBERMAN: But Gary, let me just make two comments. First of all, there are some laboratory-based measures that have begun to be reflected in the DSM. It's reflecting kind of the first introduction of those in the history of mental illness and description in the DSM. So for Alzheimer's disease, there are genes that can inform the diagnosis that are described in the DSM for familial forms of Alzheimer's disease. And similarly, for narcolepsy, there's the measurement of hypocretin in the CSF that can be used to inform the diagnosis. And what we're seeing is the first introduction, you know, like a leading edge of medical research that is allowing for that.

GREENBERG: I think, you know, one of the things to consider here is we're dealing with the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions. Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos. And I don't think anybody wants to go back to that. I don't think anybody right now has an alternative for clinical use beyond what the DSM is providing.

So it's easy to criticize this and to say it's not a perfect document. And I think everybody would probably endorse that sentiment. I haven't seen anything yet that could replace it for clinical use.

FLATOW: So - but according to that document, then, binge eating is a mental illness.

LIEBERMAN: Well, it's a mental disorder.

FLATOW: Binge eating?

LIEBERMAN: Binge eating.

FLATOW: How do you diagnose binge eating?

LIEBERMAN: Well, binge eating is one of what would be called an eating disorder, right? So the characteristic disturbance is in feeding in satiety, and in a consumption of food. Anorexia has been kind of the most - a prototype for eating disorders, and it's been known historically to occur. Nobody would doubt the fact that it has pathologic consequences. It's disturbing to a person. It's potentially injurious to a person.

INSEL: It has the highest mortality of any disorder in the book.

LIEBERMAN: Right. So...

INSEL: About 10 percent mortality.

So binge eating has emerged in modern culture as another form of a feeding disorder. Now, why it occurs and to what degree it's sort of genetically or biologically based remains to be determined. But, at the least, it's something which a number - what people suffer from, it causes them great distress. It's clearly sort of deviant from normative behavior. And it has potentially non- salutary consequences to them and...

GREENBERG: Ira - sorry. I'm sorry.

LIEBERMAN: And we see, you know, culture interacting with humans in a way which changes sort of the way disease is expressed. When smoking became a fashionable and prevalent practice in our society, rates of pulmonary disease increased. Because now we have such abundance of food and we have the types of fast foods that are available at low cost, we see an increase in obesity, which increases the rate of cardiovascular disease and diabetes.

FLATOW: OK, OK...

LIEBERMAN: It's reasonable to think that binge eating has emerged in a similar context.

FLATOW: Let me remind everybody that this is SCIENCE FRIDAY, from NPR. I'm Ira Flatow. Gary, did you want to jump in before the break (unintelligible)?

GREENBERG: Yeah. I'm sorry to have interrupted before. I just wanted to say that one of the legitimate functions of the DSM is to provide for treatment. And I know it's not a treatment manual, but the idea of turning binge eating disorder into a medical diagnosis is to encourage people to research it and to look for treatments. I think that that's got to be understood. And the problem with that - I mean, obviously, on the one hand, that's a good thing, if what you're doing is you're attracting attention to a widespread form of suffering.

The problem with it is the one that your question implied, Ira, which is that: Where do you draw the line? Now, nobody's very good at defining disease. We want to think that a disease is a form of suffering caused by a biological pathology, but that's simply not true. And what's happened with the DSM - because psychiatry is relatively without these biological markers - is that it has become possible to pathologize a wide swath of human suffering. And I think that part of the - let's go back to Dr. Lieberman's point about my being too abstruse and philosophical.

It's not abstruse and philosophical when people go into a doctor's office, get a diagnosis of a mental illness, that diagnosis not only follows them around for the rest of their lives, it determines the treatment. It sometimes determines the drugs they're taking, and it determines, often, their identity. It tells people how to think about their suffering in a way that telling somebody they had kidney disease does not, because we're talking about the human mind. We're talking about the self. I don't think that's a philosophical issue. I mean, it is a philosophical issue, but I also think it's a right-on-the-ground, pragmatic, concrete issue.

FLATOW: 1-800-989-8255. Let's go to Dave in Pittsburgh. Quickly, Dave, before the break.

DAVE: Hi, guys. You've been all very gentlemanly, but there's an economic side to this that I just think has to be talked about. With each version of the DSM, there has been more and more diseases or disorders identified. And each one of those disorders is given a code number, and those code numbers are like gold. That code number allows cash to flow, because with that number, you can fill in a claim form, and that causes insurance companies to pay. Now, that could be an innocent sidelight, but the fact is that in the writing of the DSM-IV, over 50 percent of the members of the committee had direct financial ties to at least one drug company. The DSM-V, at least 60 percent had direct financial ties to at least one drug company. Now, it's all nice to talk about professionalism, but the American Psychiatric Society. And so...

FLATOW: Hang on, David. Hang on.

DAVE: OK.

FLATOW: We're going to take a break and talk about this. This is an important part of the discussion. We'll be right back after this break.

DAVE: OK.

FLATOW: Everybody stay with us.

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FLATOW: I'm Ira Flatow. We're talking this hour about diagnosing mental illness, why some psychiatrists and psychotherapists are opposed to the profession's new manual that just came out, the DSM-V. Gary Greenberg is a practicing psychotherapist, author of "The Book of Woe: The DSM and the Unmaking of Psychiatry." Thomas Insel is the director of National Institute of Mental Health, Jeffrey Lieberman, president of the American Psychiatric Association. Our number: 1-800-989-8255.

On the phone, Dave in Pittsburgh brought up a very interesting case. Dave, you were saying that there is a strong tie between the drug companies and the DSM. Let me just - hold your thought there, and see if I can get some reaction to that.

GREENBERG: Could I jump in here, Ira?

FLATOW: Gary, go ahead.

GREENBERG: Yeah. First of all, I'm sure that Jeff will speak to the way the APA has made strides in distancing itself from the drug companies. But what I want to say is I'm the person who would be most motivated, I guess, to find conspiracies out there, since I'm a journalist, and there aren't conspiracies. There's no attempt to plant - you know, these industry ties or unseemly, and they reflect the entanglement of psychiatry with the drug industry. But there's nobody planting disorders in the DSM in order to get drug money. You know, you don't need conspiracies like that when you have capitalism.

Every diagnosis is a market, whether the people who make the diagnosis up intend it to be that way or not. And that's a symptom of a health care system that's in trouble. So that's a much larger problem. But as to the specifics of it, the issue here is that the psychiatrists and the drug industry have a similar take on psychological suffering, which is that it is a medical problem that is, by and large, to be treated with drugs.

FLATOW: Not your take, I take it?

GREENBERG: Well, you know, I don't have a big animus against drugs. I just think that we need to be more transparent about the fact that we don't know much about their long-term effects, that we don't know exactly why they work, that they are treating symptoms and not underlying disorders. And I think with transparency, many of the problems that I bring up in my book can be resolved. I also think that with transparency, psychiatry would be answering to maybe more critics, but I think that might be a healthy thing.

LIEBERMAN: Ira, this is Jeffrey Lieberman. I think the issue is less transparency than it is lack of progress. You know, my - there's a saying that it's better to be lucky than to be smart. Psychiatry, even though it is, in many respects, kind of a stepchild of medicine, has been lucky in the sense that, serendipitously, in the 1950s, post-World War II, when the NIH was created, when the NIMH was one of the first institutes created in the NIH, we happened to stumble upon pharmacologic compounds that worked, for the first time in human history, to alleviate psychotic symptoms of schizophrenia and antidepressants - or agents that work as antidepressants to alleviate the symptoms of severe, major depression, and then subsequently lithium and anticonvulsants as mood stabilizers.

We didn't know what the cause of the illnesses were. We didn't know exactly why the drugs were effective, but we did know that they were dramatically therapeutic. And they have remained lifesavers for countless numbers of patients who otherwise would have been institutionalized or relegated to completely incapacitated lives. The problem is that we haven't moved beyond that very far.

FLATOW: And, you know, we had the 1990s, which was the decade of the brain. Did we move far there? I mean - and then we just had President Obama saying we need the BRAIN Initiative, the $100 million jump-starting money on that. Are the - why aren't moving very far?

INSEL: There are bunch of reasons. This is Tom Insel. And part of it has been, I think, the science is focused much more on the treatment than on the disorders, but that's something we can change. And I think part of it is - these are complicated problems. We haven't had great tools. Part of the excitement of the BRAIN Initiative is that we're hoping to get much better tools.

Can I just respond to Dave, though, because I think he's raised a couple - three, at least, interesting issues related to the economics?

FLATOW: Mm-hmm.

INSEL: And I'm not sure we've really responded. As Gary Greenberg said, really, the conflict of interest conspiracy that he's worried about is probably not an issue for the DSM-V. The question about whether this is generating more and more disorders, I think, does need some factual clarification. And I know I'm brought on the show as the DSM critic, but let me be clear. From my count of what's in there, we've gone from 172 disorders down to 157. So this revision is reducing the number of disorders. They're not creating new ones.

The other question about how this fits with reimbursement, I think, is also going to need a much deeper discussion because we're beginning to understand that in the new health care ecology that we're about to go into, it's not going to be your diagnosis that determines how people get paid or get reimbursed. It's going to be much more about the intervention that's used. And that's actually not at all relevant to what's in DSM-5. It doesn't specify treatments. So I think it's going to be - the actual impact on the reimbursement may be much smaller than we think.

JOE: Hi, Ira. Thanks for - thank you for taking my call. My question has to do with the history of psychiatry. I heard Mr. Lieberman - Dr. Lieberman refer to pre-DSM psychiatry as being chaotic. I happen to disagree. I think it's still chaotic. I'm wondering how all of the people there feel about how the current situation compares to, say, the beginnings of American psychiatry, Benjamin Rush, the humorist theory, bloodletting as a treatment, the somatic treatments and how that compares to, say, the chemical imbalance theory of today and the drug treatment of today.

FLATOW: You sound like you have some experience with all of it.

JOE: I do. I'm a social worker here in New York City.

GREENBERG: Ira, may I answer this question?

FLATOW: Sure, Gary.

GREENBERG: So that history is really important to understand. What Tom was referring to was a period just before DSM-3 when diagnosis was based on what are called prototypical descriptions and diagnosis wasn't of much interest in the - to psychiatrists or other mental health clinicians. And then there was a crisis in psychiatry in the early 1970s. And it was one of a number of crises that have occurred historically since about the time of Benjamin Rush since the founding of psychiatry based on the question of whether or not psychiatry was credible. And that question has always been tied to the diagnostic order.

What happened in the 1970s was that there was an attempt to make psychiatry more scientific by - more credible, I'm sorry, by making the diagnoses more scientific. And that was the birth of the DSM-3, which was a book full of diagnoses with a criteria by which they could be known. And it definitely made it easier for psychiatrists to agree on what mental illness a particular patient had. What it didn't do was make it easier for us to know what's a mental disorder and what's just the normal suffering of a difficult life.

And to get back to what Tom just said about the creation of disorder, it's a complicated issue, but, in fact, he's correct. Since DSM-3, the overall prevalence of mental disorder has not changed whether the number of diagnoses goes up or down. The issue that has occurred is that in DSM-3, there was a conscious attempt to make the DSM cover as much suffering as possible. That was partly in the hope of treating a lot of people, and it was also as a way to get professional support for the new approach to diagnosis. The only way to do that was to reassure the psychiatrists and the other mental health clinicians that their patients wouldn't be excluded from diagnosis at all, and that gets back to the reimbursement question we were talking about before.

LIEBERMAN: Let me add one comment about what Gary was just saying, which I pretty much agree with. With DSM-3, which was kind of a paradigm shift in terms of the nosology that was being used for psychiatric disorders, there were two notable changes that, I think, illustrate the way this works. One was the elimination of homosexuality, which had been classified as a disorder and, you know, clearly was mistakenly or uninformedly considered in that way.

The other was the addition of PTSD. Now PTSD, which we're all familiar with now, describes the condition that occurs as a result of emotional trauma or stress historically been recognized in wars. Going back to the Civil War, soldiers had battle fatigue, combat fatigue, shellshock, et cetera, but it had not been specifically designated in a more clinical terminology or considered to be a bona fide disorder. And we still don't know the cause of it. We know that it's precipitated by trauma, but we don't know the underlying neurobiology of it. We don't have sort of a laboratory test for it. But nevertheless, nobody disputes the fact that it is a disorder.

So the DSM does evolve in the context of knowledge and also, you know, our environment and cultural conditions. But in the aggregate, it is not expanding the pie of individuals in our society that would be diagnosed rather with carving the pie into what hopefully are more precise or more accurate slices.

GREENBERG: But let's add to that, Jeff, that under the current regime, 50 percent of the American people will suffer mental illness in their lifetime and 30 percent, close to 30 percent in any given year. Also, it's important to point out that those two moves which - the deletion of homosexuality and the addition of PTSD, both of which are great moves if you're going to have something like a DSM. Both took place by expert consensus on - basically on the basis of a vote. In fact, in the case of homosexuality, a referendum. And this is the problem of the DSM. It is that - it is presented to us as a scientific text, and yet in what other medical field are scientists voting on what a disease is?

LIEBERMAN: Oh, it's not a vote in that sense, Gary. This is basically an analysis of the literature and consideration in the context of public health needs. But if you look at...

GREENBERG: Excuse me.

LIEBERMAN: But there are other disorders. Let's take irritable bowel syndrome. Let's take migraine headaches. There are conditions for which we do not have clear biological measures or known ideologies that are nevertheless distressing and harmful to people require treatment by physicians and the specialty that they occur in needs to make some determination as to how to characterize it and how to define it. And if in the absence of having these objective measurable tests that needs to be done by some clinical consensus based on the extant scientific literature, that's the best way to they know to do it.

GREENBERG: Yes. And that can't be denied. I'd just say two things about that. One of them is that psychiatry, as I said earlier, is the only field as you says - I think you said it's a stepchild - it's the only field that can't - hasn't been able to keep up with this. With respect to all of its diagnoses, and I think that's an important problem. It doesn't mean that psychiatry is not a valuable profession. It means that it needs to be understood where it fits in in the panoply of scientific medicine.

LIEBERMAN: Using your metaphor of a race, I would say we're running as fast as we can.

(LAUGHTER)

LIEBERMAN: And if I can make a plea and maybe a pitch for my colleague, Tom, it would be great if we had more funding that supported research on the brain in - particularly areas that affect mental and behavioral functions because it's been tough. I mean, I've been in this business as has Tom Insel for, you know, 30 plus years. We've devoted our life to research and patient care. And at the beginning, I don't think we would've anticipated how hard it really was going to turn out to be.

FLATOW: OK. I'm going to have to end it there, and a very interesting discussion. Let me thank Gary Greenberg, a practicing psychotherapist, author of the book of "The Book of Woe: The DSM and the Unmaking of Psychiatry," Thomas Insel, who is director National Institute of Mental Health, Jeffrey Lieberman, president of the American Psychiatric Association, professor and chairman of psychiatry at Columbia. Gentlemen, thank you all for taking time to be with us today.